Non-calcified fibroids are hypoechoic relative to the surrounding myometrium; high echogenic areas result from calcification anxiety symptoms 6 week pregnancy purchase 10mg hydroxyzine with mastercard. Abdominal masses in children include Burkitt lymphoma anxiety keeping me up at night cheap 10 mg hydroxyzine fast delivery, other lymphoma anxiety 7 question test 10mg hydroxyzine with mastercard, Wilms tumour and teratoma anxiety symptoms zollinger purchase hydroxyzine 10 mg mastercard. Many Burkitt lymphomas occur in the abdomen, located around the kidney, ovary, liver or retroperitoneum. Other lymphomas are often associated with mesenteric lymphadenopathy and present as rounded hypoechoic masses usually located near the midline at the root of the mesentery. Wilms tumour develops in children between 2 and 4 years of age and grows as an intrarenal mass, poorly differentiated from the kidney. Wilms tumours often grow into the inferior vena cava, whereas neuroblastomas displace the abdominal vessels. Children with "periodic syndrome" have pain for 1 day, are pale, vomit, have fever and normal stool examination. The major causes are nonspecific colic or mesenteric adenitis usually associated with a viral infection. Physical examination assessment of pregnancy rapid pulse, raised temperature general appearance (additional illness, acute and chronic. Although a random urine sample can be used, an early morning urine sample is more sensitive. The test can become positive as early as a few days after the first missed period, but a negative test does not rule out early pregnancy. Common indications for scanning during normal pregnancy are: estimation of gestational age (after first trimester) confirmation of the presence of a pregnancy and fetal viability multifetal pregnancy date/size discrepancy fetal position (see Section 5. The symptoms of pre-eclampsia are hypertension and proteinuria In mild preeclampsia elevated blood pressure is below 160/110 mmHg and proteinuria is 0. In severe pre-eclampsia blood pressure is above 160/110 mmHg on two occasions at least 6 hours apart, and urine protein is more than 5 g/24 hours. Urinary tract infection occurs more frequently in pregnant women, whose muscles lining the ureters are more relaxed and because of the pressure of the uterus. Urinary tract infection may be asymptomatic in 178 Good clinical diagnostic practice pregnant women. A midstream urine sample should be examined by microscopy to exclude an infection. Anaemia due to iron and folic acid deficiency is more common in pregnant and lactating women, who have an increased demand for iron and folic acid for haemoglobin biosynthesis. Haemoglobin should be determined in all pregnant women as soon as possible and for some time after delivery. Women should receive iron and folic acid supplementation during pregnancy and lactation. At the level of district hospitals in developing countries about 60% of pregnancies are complicated. Complications in pregnancy can be separated into those which are most likely to occur at any time in pregnancy, and those related to the different trimesters or delivery. Complications occurring at different stages of pregnancy are discussed in the following sections. Molar pregnancy (tumour of the products of conception: 80% are benign; 15% are locally invasive; 5% are malignant). Hyperemesis gravidarum: vomiting in pregnancy severe enough to cause profound metabolic changes. Retention of urine: due to elongation of the urethra and compression by a retroverted uterus. Disorders of fetal growth Small for gestational age Definition: fetuses less than the 10th percentile for growth are termed small for gestational age. Down syndrome or any other trisomy, Turner syndrome, anencephaly, neural tube defects) intrauterine infections of various origins. Intrauterine growth restriction decreased nutrition and oxygen transmitted across the placenta maternal causes: hypertension, renal failure, anaemia, malnutrition placental causes: placenta praevia, placental infarction. Additional causes of small babies according to the gestational age multiple gestations, oligohydramnios. Placental (50%) Placenta praevia (low-lying placenta which covers the internal cervical os; complete means total covering, marginal means the edge of the placenta reaches the margin of the os). Mothers with a history of smoking, previous caesarean section, multiparty, multiple gestation, increased maternal age and erythroblastosis, are at high risk of developing placenta praevia. Bleeding results from small disruptions in the placental attachment during the normal development and thinning of the lower uterine segment during the third trimester. The main risk for placental abruption is hypertension, trauma, short umbilical cord, hydramnios, old maternal age, drug misuse, pre-term rupture of membranes. Maternal Uterine rupture due to uterine scares, abdominal trauma, abnormal placentation, overdistension, multiparty, large fetus, abnormal position of the fetus. Clinical features: sudden onset, shock, fetal distress or disappearance of fetal heart beat, pain, vaginal bleeding. Fetal Fetal vessel rupture mainly due to velamentous cord insertion (cord between amnion and chorion, unprotected from the membranes). Polyhydramnios: due to maternal causes (diabetes mellitus, benign placental tumours) and fetal causes (multiple pregnancy, anencephaly, oesophageal/duodenal atresia, absence of kidneys, hydrops foetalis) Oligohydramnios: due to poor placental function, fetal growth retardation, renal agenesis. Malpresentation: breech, transverse position-may be due to fetal congenital abnormality. High head near term: poor position of the fetus, angle of the pelvic brim, pelvic tumours, pelvic disproportion, hydramnios, placenta praevia. Fetal death causes: diabetes, Herpes simplex, malaria, hypertension, chronic renal disease. Disorders of amniotic fluid the normal amount of amniotic fluid is 800 mL at about 28 weeks and 500 mL at 40 weeks. The patient should be referred to a hospital with an obstetric facility to avoid complications during delivery. Normally a multiple gestation is suspected when a date-size discrepancy of the uterus has been diagnosed. Very often the medical history of the pregnant woman reveals a history of twins in the family. Clinical feature: Maternal fever, fetal tachycardia, uterine tenderness, smelling vaginal discharge. Fetal death Definition: lack of fetal heart rate at or beyond 20 weeks of gestation Causes: all complications mentioned above (in addition: cord compression, utero-placental insufficiency). Other causes of pre-term labour: multiple pregnancy polyhydramnios ante partum haemorrhage uterine abnormalities.
Most patients recover in seven to ten days anxiety symptoms severe buy generic hydroxyzine 10 mg on line, but some go on to develop the severe form of the disease anxiety klonopin buy hydroxyzine 10 mg. Ultrasound fluid in bowel anxiety keeps me from sleeping hydroxyzine 25 mg without a prescription, peristalsis (obstruction) enlarged sigmoid colon (sigmoid volvulus) bowel invagination (intussusception) intraperitoneal fluid (peritonitis) ectopic pregnancy anxiety symptoms 24 7 trusted 10 mg hydroxyzine, intra-abdominal abscess, hydrosalpinx and tuboovarian abscess. Guidelines for diagnostic imaging X-ray: acute abdomen Diagnostic imaging is helpful to plan correct surgical intervention and to avoid unnecessary and potentially dangerous surgical intervention. For suspected perforated gastric ulcer, an X-ray should be performed as soon as possible. For the lateral decubitus view, the patient should be left in this position for a few minutes to allow the air to 172 Good clinical diagnostic practice rise. The chest X-ray may be the best view for visualizing free air under the diaphragm. In some patients with abdominal obstruction, the patient may be given diluted water-soluble contrast medium to drink, and the passage of the contrast followed through the bowel for a few hours in order to localize the site of obstruction. In a child with a suspected ileocolic intussusception, radiological reposition may be performed, but this must be carried out only by an experienced radiologist. An intravenous pyelogram may also be made if well trained radiological staff are available and a physician is present during the injection of the contrast medium. Ultrasound: acute abdomen In case of gastrointestinal obstruction, distended, multiple fluid-filled loops of bowel are likely to be caused by either paralytic ileus or mechanical small bowel obstruction. Obstruction of the colon is likely to be due to sigmoid volvulus, which in some regions is endemic in adult males. Typically, abnormal thickening of the sigmoid wall and enlarged target configurations are seen. The characteristic appearance of intussusception is of a "doughnut" or "target", with the image of two hypoechoic rings. Peritonitis appears as intra-abdominal fluid with different echoes, according to the consistency of the fluid (pus, blood, clots). Examination of clinical symptoms and signs 173 Perforation of peptic ulcers and typhoid bowel show air in the abdominal cavity. Intra-abdominal abscesses (subphrenic abscess, abscesses between loops of bowel, pelvic abscess, perinephric abscess) can be demonstrated as masses with or without a wall and various echogenity within the respective area. The distinction between hydrosalpinx and tubo-ovarian abscess and ectopic pregnancy is difficult. A tubo-ovarian abscess usually has a complex internal appearance with low-level echoes arising from the inflammatory fluid but ectopic pregnancy may mimic this appearance. Amoebic colitis, acute pancreatitis, appendicitis, acute pelvic inflammatory disease in women, ectopic pregnancy, liver abscess: see under the respective sections. X-ray: non-acute abdominal pain A cholecystogram using fat-soluble contrast medium, given orally, can be performed by an experienced radiologist. A negative examination ("normal gallbladder") does not rule out the presence of gallbladder disease; however the presence of stones gives a clear diagnosis. An intravenous cholangiogram examination should only be performed in hospitals with well trained radiological and anaesthetic staff, due to the danger of severe adverse reactions from the contrast medium. Barium swallow using either a single contrast or double contrast technique for examining the stomach and the duodenum should be reserved for hospitals with qualified radiologists. Ultrasound: non-acute abdominal pain Echinococcus cysts of the liver show a typical appearance of multiple cysts with calcification, although this appearance does not exclude other cystic diseases such as liver abscess and amoebic abscesses. They appear as single or multiple masses within the uterus, which can be considerably enlarged. Fetal heart near the fundus, breech can be palpated in the pelvis or by vaginal examination. Ultrasound investigations during pregnancy and delivery Ultrasound examinations are made when pathological features are expected, or when the findings of the midwives are not consistent with the history of the patient. The person making the examination should not tell the pregnant women the diagnosis during the investigation, not only in severe findings such as fetal death or ectopic pregnancy but also confirming a twin pregnancy or an intact pregnancy. The observations and their consequences should be rather discussed with the patient after the examination in appropriate surroundings. It may be even advisable to tell the findings to a nurse or midwife who comes from the same community as the patient and therefore may be more qualified to discuss the problems the patient may have to face. Estimation of gestational age Uncertainty about gestational age occurs when patients cannot accurately remember the date of the last menstrual period, or when menstruation had not resumed due to breast feeding. During the second and third trimesters, biparietal diameter and femur length are used to demonstrate fetal growth. Tables for fetal age assessment are usually provided within the operating manual of the scanner. In case of decreased fetal growth, both parameters are less than the 10th percentile according to the tables. The abdominal circumference can be assessed as a third parameter, although it is less accurate. When all parameters, such as biparietal diameter, femur length and abdominal circumference, are 10 to 15% higher than expected, they indicate that a fetus is too large for its gestational age. Signs of fetal death include lack of fetal heartbeat, oligohydramnios (scanty amniotic fluid), hydrops foetalis (generalized oedema of the fetus), overlapping of the cranial sutures. Ectopic pregnancy Any pelvic mass in a woman of childbearing age should be considered an ectopic pregnancy until proved otherwise. If the ultrasound investigation is difficult, it should be repeated several times and confirmed by a second investigator. Ectopic pregnancy can mimic a complex adnexal mass, especially the "chronic ectopic pregnancy" in combination with sexually transmitted infection where the typical signs of acute abdomen are missing. Missed abortion shows retention of products of conception with a non-viable fetus. Molar pregnancy Molar pregnancy shows a typical pattern of multiple small anechogenic structures within the echogenic tissue. Uterine disorders Uterine fibroids appear as hypoechoic masses inside the uterus, or may be pedunculated, in addition to an existing pregnancy. A bicornuate uterus shows a normal pregnancy in one horn, with a thickened endometrium in the other horn. In suspected fetal growth retardation, the following may be demonstrated: abnormally small placenta, areas of thrombosis and placental infarction reflecting premature senescence. Placing the patient in the Trendelenburg position may assist in obtaining a precise picture. Abruption of the placenta can only be demonstrated by the presence of a retroplacental clot, in rare cases. Fetal disorders Fetal abnormalities can be clinically suspected when there is evidence of oligohydramnios or hydramnios. However, not all anatomical abnormalities of the fetus can be detected by ultrasound. Multifetal pregnancy Sonographically it is important to be aware of two types of twinpregnancy. Chapter 6 Epidemics An endemic disease is a disease which is usually present in a community at all times but with relatively low incidence. Something that is endemic is typically restricted or peculiar to a locality or region. An epidemic disease is a disease which occurs in more than usual numbers in a community. Therefore, an epidemic is usually recognized by an increase in the numbers of cases of a disease. Even a single case of a disease may constitute an epidemic if the disease is not normally present in the community. A pandemic occurs when an epidemic becomes very widespread and affects a whole region, a continent, or the entire world. Outpatient morbidity data most closely resemble diseases present in the community.
Now that the team has thought through some of the challenges anxiety scale 0-5 trusted 25mg hydroxyzine, it is able to focus its improvement efforts for this particular part of the care system anxiety urination order hydroxyzine 25mg online. The team continues to look at different parts of the pathway to identify relevant impacts for each part anxiety heart rate generic 10mg hydroxyzine otc. Once it is able to evaluate where there are potential opportunities for improvement anxiety knee pain buy 25mg hydroxyzine free shipping, it can use this information to target its efforts. Additional examples of strategies to improve care for the Breast Cancer Screening quality measure are described in the Improvement Strategies section of this module. Once the team visualizes the pathway and identifies opportunities for improved care, the next step is to collect and track data to test and document them. This step is essential for understanding the performance of its current care processes, before improvements are applied, and then monitoring its performance over time. It is important to recognize that different types of data are collected during the improvement project. First, data to calculate and monitor the Breast Cancer Screening performance measure results is needed. Monitoring a performance measure involves calculating the measure over time and is used to track progress toward a numerical aim. A detailed and stepwise approach follows to explain the types of infrastructure elements needed to gather data to support improvement. Second, changes an organization is making to improve care processes and their effects must be tracked. Tracking the impact of changes reassures the team that the changes caused their intended effects. A baseline is the calculation of a measure before a quality improvement project is initiated. It is later used as the basis for comparison as changes are made throughout the improvement process. For the Breast Cancer Screening measure, an organization can determine the percentage of patients aged 40 to 69 years who have had a mammogram during the last two years. Baseline data is compared to subsequent data calculated similarly to monitor the impact of quality improvement efforts. The details of how to calculate the data must be determined to ensure that the calculation is accurate and reproducible. The difference between how an organization provides care now (baseline) and how it wants to provide care (aim) is the gap that must be closed by the improvement work. The next step of data infrastructure development involves a process in place to calculate the measure over time as improvements are tested. This involves deciding how often to calculate the measure and adhering to the calculation methodology. The next section describes in more detail how to develop a data infrastructure to support improvement. Implementation of Quality Measure:: Breast Cancer Screening this section explores each step to create the data infrastructure used to improve performance on the measure, Breast Cancer Screening. Rationale/Purpose: Breast cancer continues to be a leading cause of morbidity and mortality in the U. The goal is to further reduce the morbidity and mortality associated with breast cancer. Regular mammograms for women aged 50 to 69 years can reduce breast cancer mortality by up to 35 percent through early detection, and a mammogram can detect breast cancer one to four years before a woman can feel the lump. Mammography can also detect 80 to 90 percent of breast cancers in women without symptoms. Numerator/Denominator: Numerator: Women in the denominator who received one or more mammograms during the measurement year or the year prior to the measurement year. Denominator: All women patients aged 42 to 69 years during the measurement year or year prior to the measurement year. Denominator Exclusions/Inclusions/Notes/Comments: Denominator Exclusion: Women who had a bilateral mastectomy and for whom administrative data does not indicate that a mammogram was performed; the bilateral mastectomy must have occurred by December 31 of the measurement year. Numerator/Exclusions/Notes/Comments: Numerator Exclusions: None Numerator Inclusions: Documentation in the medical record must include: a note indicating the date the test was performed and the result of the finding (or a copy of a mammogram result), or a note that documents the date and results from a test ordered by another provider. Step 1 - Determine and Evaluate the Baseline As previously discussed, a baseline for improvement is a calculation that provides a snapshot of the performance of the systems of care for a measure before improvements are applied. The baseline is determined by calculating the measure and collecting the information for the numerator and denominator. While electronic methods are more efficient once established, manual chart audits using random sampling techniques are equally valid. Consistent data collection sources and methodologies are critical to ensure reliable data. The following tables depict a decision algorithm for the measure, Breast Cancer Screening. The algorithm outlines the steps that an organization follows to determine its baseline and monitor improvements for Breast Cancer Screening. Identify the Denominator the denominator for this measure is all women patients aged 42 to 69 years of age during the measurement year or year prior to the measurement year. Use a two-year date range: the measurement year and the year prior to the measurement year. Unilateral mastectomy (must have 2 separate occurrences on 2 different dates of service) bilateral mastectomy a. Administrative Method: Audit all submitted claims or encounters for patients in the denominator and include those with the following codes: i. Medical Record Audit: Audit all patients in the denominator or use valid sampling methodology. Include the patient in the numerator if the documentation in the medical record includes: i. Decide if the performance is satisfactory based on available data from reliable sources. An organization with a low performance may want to allow a longer time to achieve excellence, but striving to reach screening rate greater than 75 percent is feasible for most. If the performance is satisfactory, an organization may wish to choose another measure and focus on other systems of care. If the performance is unsatisfactory, consider adopting the measure and using it to monitor improvements to the care delivery system. An organization should understand that if a measure is adopted for improvement, ongoing and regular measurement is necessary to reach and sustain its organizational goals. More information regarding measurement can be found within the Managing Data for Performance Improvement module. It is important to remember this gap in performance is defined as the difference between how the care processes work now (baseline) and how an organization wants them to work (aim). An organization may often modify its aim or timeline after analyzing its baseline measurement and considering the patient population and organizational constraints. As an organization moves forward, the baseline is used to monitor and compare improvements in care over time. While it is important for an organization to stay focused on its aim, it is equally significant to periodically celebrate the interim successes. Step 2 - Create a reliable way to monitor performance over time as improvements are tested. An organization should standardize its processes and workflows to ensure the team collects and calculates performance data the same way over time. Document exactly how the data is captured so staff turnover does not interfere with the methodology. Monthly measurement is recommended, if feasible, as it is associated with a higher level of team engagement and success. Less frequent performance measurements are adequate for reporting 26 Breast Cancer Screening purposes, but do not adequately support improvement efforts. An advanced discussion can be found in the Managing Data for Performance Improvement module. A simple chart audit form is appropriate for manual audits and can be repeated frequently as desired.
Lesions of the posterior visual pathway anxiety 2020 episodes cheap hydroxyzine 25mg visa, including the lateral geniculate anxiety symptoms legs generic hydroxyzine 25mg on line, optic radiations anxiety coach buy discount hydroxyzine 10 mg online, and occipital cortex anxiety symptoms hives hydroxyzine 25mg lowest price, have normal pupillary light reactions but are expressed by loss of visual fields. At older, cooperative ages, children can be asked to smile, blow out their cheeks, blink forcibly, and furrow their foreheads. Weakness of all unilateral muscles of the face, including the forehead, eye, and mouth, indicates a lesion of the ipsilateral peripheral facial nerve (Bell palsy). Because the upper third of the face receives bilateral cortical innervation, if the weakness affects only the lower face and mouth, a contralateral lesion of upper motor neuron in the brain (tumor, stroke, abscess) must be considered. Hearing can be tested in a verbal child by whispering a word in one ear while covering the opposite ear. If there are any concerns about hearing, formal audiologic assessment is indicated. Nystagmus is an involuntary beating eye movement with a rapid phase in one direction and a slow phase in the opposite direction. By convention, the direction of the nystagmus is defined by the fast phase and may be horizontal, vertical, or rotatory. With unilateral third cranial nerve (oculomotor nerve) palsy, the involved eye deviates down and out (infraducted, abducted), with associated ptosis and a dilated, mydriatic pupil. Weak, breathy, or nasal speech; weak sucking; drooling and inability to handle secretions; gagging and nasal regurgitation of food are additional symptoms of cranial nerve X dysfunction. In later childhood, strength in these muscles can be tested directly and individually. Facial sensation of light touch and pain can be determined with cotton gauze and pinprick. Facial sensation can be functionally assessed in an infant by gently brushing the cheek, which will produce the rooting reflex (turns head and neck with mouthing movement, as if seeking to nurse). Arm and leg movements should be symmetrical, seen best when the infant is held supine with one hand supporting the buttocks and Chapter 179 one supporting the shoulders. Power is graded as follows: 5 Normal 4 Weak but able to provide resistance 3 Able to move against gravity but not against resistance 2 Unable to move against gravity 1 Minimal movement 0 Complete paralysis Strength in toddlers is assessed by observing functional abilities, such as walking, stooping to pick up an object, and standing up from the floor. An older child should be able to easily reach high above his or her head, wheelbarrow walk, run, hop, go up and down stairs, and arise from the ground. Gower sign (child arises from lying on the floor by using his arms to climb up his legs and body) is a sign of significant proximal weakness. Subtle asymmetry can be detected when the child extends arms out in front with the palms upward and eyes closed. Muscle fasciculations indicate denervation from disease of the anterior horn cell or peripheral nerve. Cerebellar dysfunction results in a broad-based, unsteady gait accompanied by difficulty in executing turns. Corticospinal tract dysfunction produces a stiff, scissoring gait and toe walking. Extrapyramidal dysfunction produces a slow, stiff, shuffling gait with dystonic postures. A waddling gait occurs with hip weakness due to lower motor neuron or neuromuscular disorders. A steppage gait results from weakness of ankle dorsiflexors (common peroneal palsy). In extrapyramidal disease, an increase in resistance is present throughout passive movement of a joint (rigidity). Tone Deep tendon reflexes can be elicited at any age and are reported on a 5-point scale: 0 Absent 1 Trace 2 Normal 3 Exaggerated reflex, with spread to contiguous areas (tapping a patellar reflex and observing a bilaterally brisk quadriceps response) 4 Clonus (self-limited or sustained) these reflexes are decreased in lower motor neuron diseases and increased in upper motor neuron disease. Babinski response, or extensor plantar reflex, is an upward movement of the great toe and flaring of the toes on stimulation of the lateral foot and is a sign of corticospinal tract dysfunction. This reflex is unreliable in neonates except when asymmetrical because the "normal" response at this age varies. By 12 to 18 months of age, the plantar response should consistently be flexor (toes flexing down). Excessive muscle bulk is seen in rare conditions, such as myotonia congenita; boys with Duchenne muscular dystrophy have pseudohypertrophy of their calves. Observation and functional analysis help assess coordination in infants and toddlers. Exchanging toys or objects with the child permits assessment of intention tremor and dysmetria (errors in judging distance), signs of cerebellar dysfunction. Cooperative children can do repetitive finger or foot tapping to test rapid alternating movements. Cerebellar and corticospinal tract dysfunction produce slowing and irregularity during tests of rapid alternating movements. The sensory examination of newborns and infants is limited to observing the behavioral response to light touch or gentle sterile pinprick. In a cooperative child, the senses of pain, touch, temperature, vibration, and joint position can be tested individually. The cortical areas of sensation must be intact to identify an object placed in the hand (stereognosis) or a number written in the hand (graphesthesia) or to distinguish between two sharp objects applied simultaneously and closely on the skin (two-point discrimination). Spikes, polyspikes, and spike-and-wave abnormalities, either in a localized region (focal) or distributed bihemispherically (generalized), indicate an underlying seizure tendency. Spontaneous discharge of motor fibers (fibrillations) or groups of muscle fibers (fasciculation) indicates denervation, revealing dysfunction of anterior horn cells or peripheral nerves. Abnormal muscle responses to repetitive nerve stimulation are seen with neuromuscular junction disorders, such as myasthenia gravis and botulism. The amplitude and duration of the muscle compound action potentials are decreased in primary diseases of muscle. Cranial ultrasonography is a noninvasive bedside procedure used to visualize the brain and ventricles of infants and young children with open fontanelles. There are three key features present: background patterns, behavioral state modulation, and presence or absence of epileptiform patterns. The background varies with age, but there should be general symmetry and synchrony between the background of the two hemispheres without any localized area of higher amplitude or slower frequencies (focal slowing). Fixed slow wave foci (1 to 3 Hz) delta rhythms suggest an underlying structural abnormality (brain tumor, abscess, stroke). Headaches can be a primary problem (migraines, tension-type headaches) or secondary to another condition. Secondary headaches are most often associated with minor illnesses such as viral upper respiratory infections or sinusitis, but may be the first symptom of serious conditions (meningitis, brain tumors), so a systematic approach is necessary. Each pattern (acute, recurrent-episodic, chronic-progressive, chronic-nonprogressive) has its own differential diagnosis (Table 180-1). Tension-type headaches are the most common recurrent pattern of primary headaches in children and adolescents. The pain is global and squeezing or pressing in character, but can last for hours or days. Headaches can be related to environmental stresses or symptomatic of underlying psychiatric illnesses, such as anxiety or depression. Migraine headaches are another common type of recurrent headaches and frequently begin in childhood. Headaches are stereotyped attacks of frontal, bitemporal, or unilateral, moderate to severe, pounding or throbbing pain that are aggravated by activity and last 1 to 72 hours. Associated symptoms include nausea, vomiting, pallor, photophobia, phonophobia, and an intense desire to seek a quiet dark room for rest. Toddlers may be unable to verbalize the source of their discomfort and exhibit episodes of irritability, sleepiness, pallor, and vomiting. Migraines can be associated with auras that may be typical (visual, sensory, dysphagic) or atypical. Aura can precede or coincide with the headache and typically persists for 15 to 30 minutes. Visual auras consist of spots, flashes, or lines of light that flicker in one or both visual fields. Atypical auras may also consist of brief episodes of unilateral or perioral numbness, unilateral weakness, or vertigo that persist for hours, then resolve completely. Common causes of secondary headaches include head trauma, intercurrent viral illness, and sinusitis. Focal neurological deficits, alteration of consciousness, or a chronic progressive headache pattern may warrant imaging. In these cases, brain magnetic resonance imaging, with and without gadolinium contrast, is the study of choice, providing the highest sensitivity for detecting posterior fossa lesions and other, more subtle abnormalities.
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